Abstract
Background:
Unhealthy alcohol use is increasing among older adults, particularly women. We estimated gender differences in the prevalence of alcohol screening/discussions with healthcare providers among older adults who use alcohol.
Methods:
Using the 2015-2019 National Survey on Drug Use and Health, we included 9,663 adults ages 65 and older in the United States who used alcohol and had a past-year healthcare encounter. We estimated the weighted prevalence of alcohol screening/discussions (no screening; screening only; discussions with providers) by gender. We used weighted multinomial logistic regression models to examine correlates of alcohol use screening/discussions.
Results:
Among older adults who used alcohol and encountered the healthcare system in the past year, 24.68% of men and 27.04% of women reported no alcohol screening/discussions. Men were more likely than women to be asked about drinking frequency, amount, or problems related to drinking. Compared to no alcohol screening/discussions, women were 22% more likely (95% CI: 1.05, 1.42) to report alcohol screening only but were 18% less likely to discuss alcohol with providers (95% CI: 0.73,0.91) than men. Women had 0.67 times (95% CI: 0.60, 0.74) the adjusted odds of reporting alcohol discussions with providers versus any alcohol screening only compared with men.
Conclusions:
Over a quarter of older adults who used alcohol were not asked about their drinking, and older women were less likely than men to discuss alcohol use with providers. Given the increased risk for harms of alcohol use with aging, older adults should be screened and counseled regarding their alcohol use.
Keywords: epidemiology, any alcohol screening, alcohol discussions, older adults
INTRODUCTION
Older adults are at particular risk from the harms of alcohol use given physiological changes in aging that can increase sensitivity to alcohol, the increased presence of chronic medical conditions, and an increased number of prescribed medications (Han and Moore, 2018, National Institute of Alcohol Abuse and Alcoholism). Alcohol use can therefore lead to negative consequences and complicate the management of chronic medical diseases among older adults. Previously, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommended lower drinking limits for older adults given these concerns (Han and Moore, 2018). In line with the U.S. Department of Health and Human Services and the Department of Agriculture’s “Dietary Guidelines for Americans 2020-2025” (U.S. Department of Health and Human Services and U.S. Department of Agriculture, 2021), NIAAA now recommends up to one drink per day for women and up to two drinks per day for men for all adults, while some adults who take certain prescribed medications or have certain medical conditions are advised not to consume alcohol (National Institute of Alcohol Abuse and Alcoholism, 2020, U.S. Department of Health and Human Services and U.S. Department of Agriculture, 2021). Despite these recommendations, unhealthy alcohol use, which encompasses the spectrum of alcohol use that can have negative health consequences and includes at-risk alcohol use to alcohol use disorder, is increasing among older adults nationally. Over the past decade, there were sharp increases in high-risk drinking, binge drinking, and alcohol use disorders among adults age 65 and older (Grant et al., 2017, Han et al., 2017).
While older men have higher rates of both alcohol use and unhealthy alcohol use, the gender gap is narrowing among older adults, as these rates are increasing considerably among older women (Grant et al., 2017, Han et al., 2017). Past-month binge drinking increased by 44.4% and alcohol use disorders by 84.6% among older women from 2005 to 2014 (Han et al., 2017). Yet older women may be at particular risk for experiencing adverse effects associated with alcohol use given their lower metabolism of alcohol and larger physiological changes in lean body mass with aging compared to men and the association of alcohol use and certain breast cancers (Li et al., 2010, Shield et al., 2016). With the increase in older adults engaged in potentially risky alcohol use, especially among older women (Grant et al., 2017, Han et al., 2017), alcohol screening and intervention should be routine in this population. However, alcohol use by older women is often overlooked and older women are less likely to screened for or seek help for problems related to alcohol use (Han and Moore, 2018, Blow and Barry, 2002).
In 2018, the US Preventive Services Task Force published its recommendation statement on “Screening and Behavioral Counseling Interventions to Reduce Unhealthy Alcohol Use in Adolescents and Adults.” Recommendations included screening for unhealthy alcohol use among adults age 18 and older along with providing brief behavioral counseling interventions for adults engaging in risky or hazardous drinking (U.S. Preventive Services Task Force et al., 2018). However, despite the known health consequences, studies indicate that alcohol screening is lower among older than younger adults (McKnight-Eily et al., 2014, Sahker and Arndt, 2017). For example, a study using national data from 2014 found that 67.4% of older adults who reported alcohol use and a healthcare visit were asked about their alcohol use by a provider, compared to an average of 76.5% of all ages 17 and older, and 79.1% of middle-aged adults 50-64 (Sahker and Arndt, 2017). There are many challenges in screening older adults for alcohol use including lack of time, discomfort for both patients and providers in discussing stigmatized behavior, and the false notion that older adults do not engage in unhealthy substance use (Han and Moore, 2018). Furthermore, unhealthy alcohol use can often be difficult to detect among older adults in the presence of chronic diseases or cognitive changes, and often goes underrecognized in this population. At a minimum, any kind of screening would begin with questions about whether an individual uses alcohol, which could then be used to identify who may or may not need further assessments. While studies have not tested gender-specific associations in older age groups, information about gender differences in alcohol screening and discussions among older adults is needed given the increases in drinking among older women.
In this study, we filled this information gap using nationally representative data of older adults age 65 and older in 2015-2019 in the United States. We included older adults used alcohol and encountered the healthcare system in the past year in order to estimate alcohol screening and discussions with providers, focusing on gender differences in the relationship between alcohol screening and discussions. We hypothesized that a large proportion of older adults would report not discussing their alcohol use with their providers, and that this gap would be more marked among older women than men.
RESEARCH DESIGN AND METHODS
Data source
We obtained data from the public-use 2015 to 2019 National Survey on Drug Use and Health (NSDUH). The NSDUH is an annual repeated cross-sectional nationally representative survey in the United States. The NSDUH utilizes a four-stage process to sample community-based individuals ages 12 and older, oversampling young people. Audio computer-assisted self-interviewing (ACASI) by lay interviewers is used to increase accuracy of reporting on sensitive topics, such as substance use. Survey methodology is described in detail elsewhere. Weighted interview response rates for adults 26 and older ranged between 63.87-67.36% between 2015-2019 (Center for Behavioral Health Statistics and Quality, 2016, Center for Behavioral Health Statistics and Quality, 2020).
Sample
Of the N = 18,794 adults ages 65 and older in the 2015-2019 NSDUH, we included n = 17,744 (94.3%) who reported a past-year healthcare encounter. This included any healthcare visit for any reason, defined as any past-year inpatient (“stayed overnight or longer as an inpatient in a hospital”), outpatient (“visited a doctor, nurse, physician assistant or nurse practitioner about your own health at a doctor’s office, a clinic, or some other place), or emergency room visit (“treated in an emergency room for any reason”). We excluded n=7,931 (43.9%) who reported no alcohol use in the past year, and then n=150 (1.5%) who were missing our alcohol screening/discussion outcome. Our final sample included 9,663 adults ages 65 and older in the United States in 2015-2019 who used alcohol and had a past-year healthcare encounter.
Measures
Any alcohol screening or discussions:
Respondents were asked about any alcohol screening in the past year using the following prompt: “During the past 12 months, did any doctor or other health care professional ask, either in person or on a form, if you: Drink alcohol?” Separately, respondents were asked about whether they had discussions about alcohol with their provider, and also the content of their alcohol use discussions, using the following prompt and response options: “Please think about all of the talks you have had with a doctor or other health care professional during the past 12 months when you answer this question. Choose the statement or statements below that describe any discussions you may have had in person with a doctor or other health professional about your alcohol use.” Response options included: “1. The doctor asked how much I drink; 2. The doctor asked how often I drink; 3. The doctor asked if I have any problems because of my drinking; 4. The doctor advised me to cut down on my drinking; 5. The doctor offered to give me more information about alcohol use and treatment for problems with alcohol use; 6. The doctor didn’t discuss my alcohol use with me in the past 12 months.” If an individual selected response 6, they were considered as not having a past-year alcohol discussions with a provider; responses 1-5 indicated that the individual had an alcohol discussion with a provider. Consistent with recent work reporting drug screening/discussions (Mauro et al., 2020), we used alcohol screening and alcohol discussions with provider information to create a three-level hierarchical alcohol use screening/discussion variable: 1) no screening/discussions, 2) screening only (i.e., asked about alcohol “in person or a form”, but did not discuss alcohol with a provider), and 3) any alcohol discussions with a provider (regardless of screening status).
Key alcohol and health variables:
Past-month binge drinking and perceived great risk of weekly binge drinking were assessed as binary indicators (yes/no). Binge drinking was defined as five or more alcoholic beverages on the same occasion for men and four or more alcoholic beverages on the same occasion for women. Alcohol use disorder in the past year included DSM-IV criteria (APA, 1994) for any past-year alcohol abuse and/or alcohol dependence. Lifetime chronic diseases (i.e., ever having a specific chronic disease in one’s lifetime) included heart disease, diabetes, chronic obstructive pulmonary disease (COPD), cirrhosis, hepatitis, kidney disease, asthma, cancer, and high blood pressure. We calculated the number of chronic diseases and created a binary indicator for any chronic disease, and an indicator of any two or more of the chronic diseases listed.
Sociodemographic characteristics:
The primary individual-level characteristic of interest was gender, which the NSDUH collected as a binary variable (male/female). Other sociodemographic variables included race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, or non-Hispanic “Other”), income (<$20,000; $20,000-49,999; $50,000-74,999; $75,000 or more), urbanicity (large metropolitan area, small metropolitan area, non-metropolitan area), insurance (private only, public only, both private/public, other), and year (2015-2019).
Analytic Strategy
We first divided survey weights by five to account for the five years of pooled data. All procedures included these survey weights to make estimates nationally representative and accounted for complex survey design using Taylor linearization to estimate standard errors. We assessed survey-weighted sample characteristics overall and by gender. We examined prevalence of alcohol use screening or discussions and individual alcohol use discussion questions by gender. We then fit a multinomial logistic model regressing alcohol screening/discussions on gender, controlling for key sociodemographic characteristics (i.e., race/ethnicity, income, county, ≥2 chronic diseases, and survey year). The multinomial model estimates are relative risk ratios (RRRs) comparing the likelihood of each pair of the categorical outcome options (i.e., screening only vs. no screening/discussions, discussions vs. no screening/discussions, discussions vs. screening only). The latter contrast was obtained by changing the reference outcome to “screening only” instead of “no screening/discussions.” Statistical analyses were conducted in StataMP version 15 (StataCorp, 2017).
RESULTS
Table 1 reports the sample characteristics overall and by gender. Of the 9,663 older adults with past-year alcohol use and a past-year healthcare encounter, 49.0% were male and 51.0% were female (Table 1). Older men had a higher prevalence of past-month binge drinking (21.7% versus 14.3%) and past-year alcohol use disorder (4.5% versus 1.8%) compared to women. Chronic diseases were common in this study sample with 41.7% with high blood pressure, 27.8% with heart disease, 19.0 with cancer, 18.4% with diabetes, 73.6% with any chronic disease, and 35.3% with 2 or more chronic diseases.
Table 1.
Overall and gender-stratified sociodemographic characteristics of older adults ages 65 and older reporting past-year alcohol use and at least one healthcare visit, 2015-2019 National Survey on Drug Use and Health (n=9,663)
| Characteristic | Overall N (wt. col. %) |
Men n (wt. col. %) |
Women n (wt. col. %) |
|---|---|---|---|
| Total (N, row %) | 9,663 (100.00) | 4,717 (49.01) | 4,946 (50.99) |
| Alcohol-related measures | |||
| Binge drinking, Past Month | 1,757 (18.00) | 1,057 (21.70) | 700 (14.30) |
| Alcohol Use Disorder, Past Year | 322 (3.08) | 229 (4.47) | 93 (1.75) |
| Perceived great risk of weekly binge drinking | 4,107 (43.15) | 1,643 (35.44) | 2,464 (50.56) |
| Lifetime Chronic Diseases | |||
| Any chronic disease | 7,109 (73.62) | 3,577 (76.38) | 3,532 (70.98) |
| Two or more lifetime chronic disease | 3,369 (35.31) | 1,745 (38.07) | 1,624 (32.65) |
| High blood pressure | 4,005 (41.68) | 1,882 (40.85) | 2,123 (42.48) |
| Heart Disease | 2,663 (27.79) | 1,597 (34.51) | 1,066 (21.32) |
| Diabetes | 1,760 (18.42) | 1,007 (21.69) | 753 (15.28) |
| Cancer | 1,823 (18.97) | 885 (19.16) | 938 (18.79) |
| Chronic obstructive pulmonary disease | 829 (8.40) | 367 (7.62) | 462 (9.14) |
| Asthma | 769 (8.14) | 293 (5.92) | 476 (10.27) |
| Kidney Disease | 407 (4.32) | 219 (4.76) | 188 (3.89) |
| Hepatitis | 177 (1.99) | 106 (2.21) | 71 (1.78) |
| Cirrhosis | 35 (0.38) | 22 (0.48) | 13 (0.28) |
| Race/Ethnicity | |||
| Non-Hispanic white | 8,234 (84.48) | 3,980 (83.72) | 4,254 (85.22) |
| Non-Hispanic Black | 586 (6.05) | 283 (5.72) | 303 (6.36) |
| Hispanic any race | 455 (5.75) | 234 (6.35) | 221 (5.17) |
| Non-Hispanic other racea | 388 (3.72) | 220 (4.21) | 168 (3.25) |
| Income | |||
| <$20,000 | 1,050 (10.06) | 392 (7.39) | 658 (12.63) |
| $20,000-49,999 | 3,250 (32.13) | 1,440 (29.36) | 1,810 (34.79) |
| $50,000-74,999 | 1,895 (19.19) | 941 (18.83) | 954 (19.53) |
| $75,000+ | 3,468 (38.62) | 1,944 (44.42) | 1,524 (33.05) |
| Urbanicity | |||
| Large metro | 4,072 (52.75) | 1,978 (52.41) | 2,094 (53.08) |
| Small metro | 3,445 (32.24) | 1,667 (32.16) | 1,778 (32.33) |
| Non-metro | 2,146 (15.01) | 1,072 (15.43) | 1,074 (14.60) |
| Insurance status | |||
| Private only | 421 (4.55) | 218 (4.89) | 203 (4.22) |
| Public only | 2,678 (27.64) | 1,383 (29.40) | 1,295 (25.94) |
| Both private/public | 6,526 (67.45) | 3,097 (65.39) | 3,429 (69.42) |
| Other | 18 (0.14) | 9 (0.09) | 9 (0.19) |
| Uninsured | 20 (0.23) | 10 (0.23) | 10 (0.22) |
| Survey Year | |||
| 2015 | 1,742 (17.80) | 829 (17.88) | 913 (17.72) |
| 2016 | 1,839 (19.15) | 873 (19.11) | 966 (19.18) |
| 2017 | 1,955 (20.51) | 999 (20.33) | 956 (20.68) |
| 2018 | 2,090 (21.08) | 1,014 (21.31) | 1,076 (20.86) |
| 2019 | 2,037 (21.47) | 1,002 (21.36) | 1,035 (21.57) |
Notes: col. = column;
Includes Non-Hispanic Asian, Native Hawaiian, Pacific Islander, Native American/Alaskan Native, and more than one race; sample sizes are unweighted, and percentages are survey weighted based on the survey weights.
Table 2 reports the prevalence of alcohol use screening/discussions overall and by gender, as well as the content of the alcohol discussion. Prevalence of the three-level alcohol use screening/discussions outcome was 25.9% no screening/discussions, 27.8% screening only, 46.3% discussions. Most common topics of alcohol discussions included amount (36.5%) and frequency (25.5%) of drinking. Overall, 53.6% of older adults who used alcohol did not discuss this alcohol use with any provider (49.1% men and 58.1% women). Among participants who had a discussion about alcohol use with their provider, a higher proportion of men than women reported being asked about drinking problems (9.8% versus 6.8%), were advised to cut down on drinking (6.8% versus 3.4%), or were offered information about alcohol treatment (2.0% versus 0.7%).
Table 2.
Prevalence of alcohol use screening and discussions among participants age ≥65 reporting past-year alcohol use and at least one healthcare visit, 2015-2019 National Survey on Drug Use and Health (n=9,663)
| Overall N (wt. col. %) |
Men N (wt. col. %) |
Women N (wt. col. %) |
|
|---|---|---|---|
| Included participants ages 65 and older who used alcohol and had at least one healthcare visit | 9,663 (100.00) | 4,717 (100.00) | 4,946 (100.00) |
| Alcohol screening/discussions | |||
| No screening or discussions | 2,430 (25.88) | 1,132 (24.68) | 1,298 (27.04) |
| Any alcohol screening only | 2,696 (27.78) | 1,151 (24.39) | 1,545 (31.03) |
| Discussions with providers | 4,537 (46.34) | 2,434 (50.93) | 2,103 (41.93) |
| Alcohol discussions content * | |||
| Doctor asked how much you drink | 3,577 (36.57) | 1,909 (39.71) | 1,668 (33.55) |
| Doctor asked how often you drink | 2,505 (25.49) | 1,372 (28.47) | 1,133 (22.63) |
| Doctor asked if any drinking problems | 423 (3.92) | 264 (5.01) | 159 (2.87) |
| Doctor advised you to cut down on drinking | 236 (2.43) | 177 (3.48) | 59 (1.43) |
| Doctor offered information about alcohol treatment | 66 (0.63) | 48 (0.99) | 18 (0.28) |
| Did not discuss alcohol with provider | 5,126 (53.66) | 2,283 (49.07) | 2,843 (58.07) |
|
| |||
| Included participants age 65 and older who discussed alcohol use with providers | 4,537 (100.00) | 2,434 (100.00) | 2,103 (100.00) |
| Alcohol discussions content * | |||
| Doctor asked how much you drink | 3,577 (78.91) | 1,909 (77.96) | 1,668 (80.02) |
| Doctor asked how often you drink | 2,505 (55.02) | 1,372 (55.91) | 1,133 (53.97) |
| Doctor asked if any drinking problems | 423 (8.45) | 264 (9.83) | 159 (6.83) |
| Doctor advised you to cut down on drinking | 236 (5.25) | 177 (6.83) | 59 (3.41) |
| Doctor offered information about alcohol treatment | 66 (1.36) | 48 (1.95) | 18 (0.67) |
Notes: Sample sizes are unweighted, and percentages are survey weighted based on the 2015-2019 NSDUH weights.
Individuals could select multiple topics of discussion, so alcohol discussion content categories are not mutually exclusive.
Table 3 reports the association between any alcohol screening/discussions and gender, accounting for individual characteristics and time. Gender differences in alcohol use screening/discussions were not explained by sociodemographic variables (including race/ethnicity, income, county, and ≥2 chronic diseases) or by time trends. Women were 22% more likely than men to report screening only (adjusted relative risk ratio [aRRR]: 1.22; 95% CI: 1.05, 1.42) and 18% less likely to report discussions with providers (aRRR: 0.82, 95% CI: 0.73, 0.91), relative to no alcohol use screening/discussions. Women were also 33% less likely than men to report discussing alcohol versus only reporting screening (aRRR: 0.67, 95% CI: 0.51, 0.74). Older adults in 2019 were also more likely to report alcohol use screening and alcohol discussions than no alcohol use screening/discussions, compared to their counterparts in 2015. However, we observed consistent gender differences in the prevalence of alcohol screening only and alcohol discussions over the study period (Figure 1).
Table 3:
Multinomial logistic regression estimating associations between sociodemographic characteristics and alcohol use screening or discussions among participants age 65 and older that had a past-year healthcare visit and past-year alcohol use, 2015-2019 National Survey on Drug Use and Health (n=9,663)
| Characteristic (N= 9,663) |
Any Alcohol Screening Only vs. No Alcohol Screening/Discussions aRRR [95% CI] |
Alcohol Use Discussions vs. No Alcohol Screening/Discussions aRRR [95% CI] |
Alcohol Use Discussions vs. Any Alcohol Screening Only aRRR [95% CI] |
|---|---|---|---|
| Gender | |||
| Male | Ref | Ref | Ref |
| Female | 1.22 [1.05, 1.42] | 0.82 [0.73, 0.91] | 0.67 [0.60, 0.75] |
| Race/Ethnicity | |||
| Non-Hispanic white | Ref | Ref | Ref |
| Non-Hispanic Black | 1.10 [0.84, 1.44] | 0.90 [0.65, 1.23] | 0.81 [0.64, 1.03] |
| Hispanic | 1.07 [0.75, 1.52] | 1.00 [0.75, 1.33] | 0.94 [0.66, 1.33] |
| Non-Hispanic Othera | 0.99 [0.65, 1.51] | 0.53 [0.37, 0.77] | 0.53 [0.38, 0.76] |
| Income | |||
| <$20,000 | Ref | Ref | Ref |
| $20,000-49,999 | 0.98 [0.82, 1.17] | 1.13 [0.92, 1.40] | 1.16 [0.96, 1.40] |
| $50,000-74,999 | 1.07 [0.85, 1.34] | 1.60 [1.28, 2.00] | 1.50 [1.21, 1.86] |
| $75,000+ | 1.30 [1.05, 1.61] | 2.06 [1.67, 2.54] | 1.59 [1.31, 1.94] |
| Urbanicity | |||
| Large metro | Ref | Ref | Ref |
| Small metro | 1.25 [1.10, 1.43] | 1.22 [1.07, 1.39] | 0.97 [0.86, 1.10] |
| Nonmetro | 1.18 [0.98, 1.43] | 1.08 [0.91, 1.28] | 0.91 [0.78, 1.07] |
| Lifetime chronic diseases | Ref | Ref | Ref |
| 0-1 | 1.57 [1.36, 1.81] | 1.60 [1.43, 1.81] | 1.02 [0.91, 1.14] |
| 2 or more | |||
| Survey Year | |||
| 2015 | Ref | Ref | Ref |
| 2016 | 1.05 [0.86, 1.29] | 1.05 [0.86, 1.29] | 1.00 [0.84, 1.20] |
| 2017 | 1.13 [0.89, 1.43] | 1.23 [1.00, 1.50] | 1.09 [0.92, 1.29] |
| 2018 | 1.29 [1.04, 1.60] | 1.12 [0.90, 1.38] | 0.87 [0.72, 1.05] |
| 2019 | 1.30 [1.05, 1.62] | 1.38 [1.15, 1.66] | 1.06 [0.91, 1.24] |
Notes: aRRR = adjusted relative risk ratio;
Includes Non-Hispanic Asian, Native Hawaiian, Pacific Islander, Native American/Alaskan Native, and more than one race.
Bold indicates significant at p < 0.05. Number of lifetime chronic diseases was based on ever having two or more of the following chronic disease in one’s lifetime: heart disease, diabetes, chronic obstructive pulmonary disease, cirrhosis, hepatitis, kidney disease, asthma, cancer, or high blood pressure.
Figure 1:
Prevalence of any alcohol screening or alcohol discussions with providers among men and women ages 65 and older reporting past-year alcohol use and at least one healthcare visit in the 2015-2019 National Survey on Drug Use and Health (n=9,663)
Note: Gender-stratified yearly prevalences for any alcohol screening only (solid lines) and alcohol discussions with providers (dashed lines) account for survey weights to derive nationally representative estimates.
DISCUSSION AND IMPLICATIONS
Using recent national data, we found that over a quarter of US adults age 65 and older who had a healthcare visit and used alcohol in the past year were not asked about any alcohol use and did not discuss any alcohol use with their healthcare providers. These results are consistent with previous studies showing that nationally, health care providers are not routinely discussing alcohol use with their older patients (Sahker and Arndt, 2017, McKnight-Eily et al., 2014). This is concerning because older adults are at high risk for the harms of alcohol use, especially for those with existing chronic disease and who take prescribed medications. As the number of older adults with unhealthy alcohol use continues to increase (Grant et al., 2017, Han et al., 2017), discussions about alcohol use are increasingly needed for this population. Our findings suggest modest increases over time in any screening or discussions compared to a 2014 sample of older adults (Sahker and Arndt, 2017), which is encouraging. Nonetheless, fewer than half of older adults who used alcohol reported any discussion about their alcohol use with a provider, indicating missed opportunities in reducing or preventing alcohol-related adverse outcomes in this population.
Our study is one of few to examine alcohol screening and discussions among older women. Most current research in alcohol screening and discussions by healthcare providers focused on pregnant women and childbearing-aged women, but older women also have distinct risks from alcohol use. Consistent with past findings among adults in ambulatory settings (Glass et al., 2016), we found that while older women who used alcohol in the past year were more likely to report alcohol screening only versus no alcohol use screening/discussions, women were less likely to discuss alcohol with a provider than men. This may be due to older women reporting less alcohol use and therefore healthcare providers deciding that alcohol use discussions were not necessary, especially in the setting of competing risks such as chronic disease management. However, given the redefining of low-risk alcohol use by the US Dietary Guidelines and NIAAA from less than 3 drinks per day to less than 2 drinks per day for women (National Institute of Alcohol Abuse and Alcoholism, 2020, U.S. Department of Health and Human Services and U.S. Department of Agriculture, 2021), and the possible increased lifetime risk of alcohol-related cancers in women with moderate drinking (Hydes et al., 2019), alcohol discussions with older women should be a part of routine healthcare.
Our study found that almost three quarters of the study sample reporting past-year alcohol use and a healthcare visit had any chronic disease, and more than a third had two or more lifetime chronic diseases. Alcohol use among older adults, even within recommended limits, can exacerbate or complicate the management of existing chronic diseases (e.g., high blood pressure, heart disease, or diabetes). Therefore, clinicians should, at a minimum, discuss with older patients with chronic diseases their alcohol use to inform their clinical care. Over the past decades, older adults received mixed messaging regarding the benefits and risks of alcohol use and may not be aware of updated guidelines or how changes in aging may put them at greater risk for harms from alcohol use. Given NIAAA’s recommendation that older adults with certain chronic diseases or those who take specific prescribed medications should abstain from alcohol use (National Institute of Alcohol Abuse and Alcoholism), older adults with chronic diseases who use alcohol should have discussions about its use with their healthcare providers to frame their risks from alcohol use in a health context (Han and Moore, 2018). In line with this clinical guideline, older adults with two or more chronic diseases who used alcohol were more likely to report alcohol screening or discussions with providers than those who did not have this chronic disease burden. Care providers have an opportunity to educate patients who may use alcohol about new guidelines regarding recommended drinking limits, and place alcohol use in a health context as it relates to their chronic diseases and medications in a non-judgmental manner.
Older adults can be asked if they used alcohol in the past year at every healthcare encounter. The USPSTF recommends utilizing 1 to 3-item screening instruments to screen for unhealthy alcohol use among all adults (U.S. Preventive Services Task Force et al., 2018). For older adults, healthcare providers can modify the Single Alcohol Screening Question (SASQ) (O’Connor, 2018) to “How many times in the past year have you had (3 for men or 2 for women) or more drinks in a day” to identify older patients who exceed low-risk drinking. Health care providers should follow up with identified patients to ensure they receive a more in-depth risk assessment follow up when clinically indicated. Researchers developed a couple of geriatric-specific screening instruments for unhealthy alcohol use. The Michigan Alcohol Screening Test – Geriatric Version (MAST-G) utilizes questions the focus more on potential stressors and behaviors common among older adults, such as drinking after experiencing a loss if drinking affects memory (Blow, 1992). The Comorbidity—Alcohol Risk Evaluation Tool (CARET) is another screening tool to identify at-risk drinkers focused on alcohol use behaviors in the setting of selected comorbidities and medications common among older adults (Moore et al., 2002). Patients who meet criteria for unhealthy alcohol use should receive brief intervention and referral to treatment when indicated. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a well-established approach for early identification and intervention for patients with unhealthy substance use used in a variety of clinical settings including primary care, inpatient care, and emergency departments. SBIRT is an evidence-based practice that appears to be more effective for reducing drinking among patients with risky alcohol use (Beich et al., 2003, Jonas et al., 2012) than among those with heavier alcohol use and alcohol use disorder (Saitz, 2010). While few studies have focused on SBIRT for older populations, there is strong evidence that SBIRT can reduce alcohol and substance use among older adults (Fleming et al., 1999, Schonfeld, 2016, Schonfeld et al., 2015).
Efforts to identify and remove barriers to discussing alcohol with older patients overall, and particularly among women, are needed in order to reduce alcohol-related harms in older adulthood. Almost everyone in the sample had public insurance, and Medicare reimburses yearly alcohol screening as well as four brief counseling sessions when indicated (Medicare.gov, 2020). Our findings could indicate that having insurance is not enough to ensure yearly alcohol screening and discussions among adults who use alcohol and encounter the healthcare system. Higher likelihood of screening and discussions among older adults in the highest income bracket could contribute to socioeconomic differences in alcohol-related negative outcomes. As screening and intervention is associated with alcohol treatment among adults with alcohol use disorder (Bandara et al., 2018), our findings indicate that gaps in alcohol screening and discussions with providers could contribute to low engagement in alcohol-related treatment services in older age.
This study has limitations worth noting. The measures used captured screening/discussions for any alcohol use, so we were not able to distinguish if SBIRT procedures were used to identify problematic alcohol use. The NSDUH did not include information about the setting of screening/discussions, so we were unable to assess whether the healthcare setting provided SBIRT programming. We also did not know the number of times an individual may have had alcohol screening/discussions, so while some individuals may have had one discussion, others could have had multiple points of intervention. Recall bias could affect the self-reported measures collected (e.g., some respondents may not remember receiving screening leading to under-reports of screening). As we did not have access to the medical record, we could not validate the self-report against administrative records or assess outcomes of any alcohol screening procedures. Despite these limitations, study strengths included the use of a large nationally representative sample of older adults capturing not only any alcohol screening/discussions, but also the content of alcohol discussions with providers.
In conclusion, we found that a substantial proportion of older adults who used alcohol were not asked about their drinking in healthcare settings, and that older women were particularly less likely to discuss alcohol use with their providers than men. These gender differences call for clinicians to engage older women in discussions about alcohol use. Targeted efforts to increase alcohol use screening and discussions among older adults in the US may be needed in light of risks related to alcohol use in the context of co-occurring health conditions that are more common in older age.
ACKNOWLEDGEMENTS AND FUNDING
The authors thank Erin Annunziato for her assistance formatting the manuscript. This work was supported by the National Institutes of Health/National Institute on Drug Abuse (K01DA045224 to PM, K23DA043651 to BH). The funding agency had no role in the study design, methods, interpretation of findings, or preparation of the manuscript.
Footnotes
CONFLICTS OF INTEREST
The authors declare no potential conflict of interest.
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